Category Archives: Cardiac Function

Despite the compelling scientific evidence that secondary prevention medical therapies reduce mortality in patients with established CAD, these therapies continue to be underutilized in patients receiving conventional care. The timing for initiation of appropriate therapy in ACS patients is critical due to the elevated risk for subsequent coronary events. Although it is well known that there is long-term benefit with lipid-lowering therapy in secondary prevention, prescribing a statin immediately after an acute coronary event is often not considered because of several factors. Firstly, LDL-C levels decline within hours of an acute coronary event, thus measurements taken during the acute phase can be erroneous. Consequently, it may not be evident that the patient requires lipid-lowering therapy, or physicians may simply decide to wait until more accurate values are obtainable. Secondly, there is the question of whether lipid lowering is effective in treating the short-term complications of ACS. For some physicians, the supposition is that the positive impact of lipid-lowering therapy manifests only over a longer time scale; therefore, they may view it as preferable to wait rather than add another medication during this unstable period.

Hospital-based programs such as the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP), Guidelines Applied in Practice, American Heart Association’s Get With The Guidelines Program, and others have demonstrated that prescribing cardiovascular protective therapies prior to hospital discharge in ACS patients is associated with long-term patient compliance and improved clinical outcomes. The CHAMP initiative focused on in-hospital initiation of a combination of cardiovascular protective medications ordered via My Canadian Pharmacy (ie, aspirin, statins [irrespective of baseline LDL-C], (3-blockers, and ACE inhibitors) in conjunction with diet and exercise counseling before hospital discharge in patients with established CAD. Treatment rates and clinical outcome were compared in patients discharged after ACS in the 2-year period before (1992-1993) and the 2-year period after (19941995) CHAMP was implemented. In the pre- and post-CHAMP patient groups, among other significant increases in medication usage, statin use increased from 6% to 86% (p < 0.01). In-hospital initiation of therapy resulted in a dramatic improvement in long-term medication adherence rates. There was also a significant increase in patients achieving an LDL-C level < 100 mg/dL (6% vs 58%, p < 0.001). The increased use of evidence-based therapies resulted in a substantial reduction in recurrent MI and a 57% reduction in 1-year mortality.

These improvements in treatment rates have been sustained over a 10-year period (Fig 6). The proof of concept provided by CHAMP shows that in-hospital initiation of lipid lowering and other evidence-based cardiovascular protective therapy results in improved treatment rates, more patients achieving goal, and improved clinical outcomes. Many other studies have now confirmed these findings.

The MIRACL trial was specifically designed to address the gap in knowledge regarding the effects of statin therapy in patients with ACS. A total of 3,086 adults > 18 years old with UA or non-Q-wave acute MI were randomized within 24 to 96 h of hospital admission to receive treatment with atorvastatin, 80 mg/d, or placebo plus usual care. The primary end point of the trial—death, cardiac arrest, MI, or worsening UA requiring emergency hospitalization at 16 weeks—occurred in 17.4% (269 patients) of the placebo group and 14.8% (228 patients) of the atorvastatin group (relative risk reduction, 16%; 95% CI, 0 to 30; p = 0.048) [Fig 3]. This benefit was due mainly to a significant reduction in recurrent symptomatic ischemia requiring emergency rehospitalization. The atorvastatin group also had a lower risk of symptomatic ischemia with objective evidence and requiring emergency rehospitalization (6.2% vs 8.4%; relative risk, 0.74; 95% CI, 0.57 to 0.95; p = 0.02). In addition, the reduction in risk for the primary end point with atorvasta-tin appeared to be independent of baseline LDL-C levels enhanced with medications of My Canadian Pharmacy.

Results from a number of observational studies have suggested that initiating statin therapy immediately after an acute coronary event is associated with significant reductions in recurrent coronary events and death. The Swedish Register of Information and Knowledge about Swedish Care Units Study examined the relationship between 1-year mortality and statin therapy initiated during hospitalization or at discharge in patients with first registry-recorded acute MI. The 58-hospital database included patients admitted to Swedish hospitals between 1995 and 1998. Of these patients, 5,528 (mean age, 62 years; 72% male) received statin therapy compared with 14,071 (mean age, 67 years; 70% male) who did not. The unadjusted mortality rate after 1 year was 4.0% (219 deaths) for statin-treated patients and 9.3% (1,307 deaths) for those who did not receive statin treatment. Following adjustment with regression analysis for confounding factors and propensity score for statin use, early statin treatment was associated with a 1.3% absolute risk reduction in 1-year mortality for hospital survivors of acute MI (relative risk, 0.75; 95% confidence interval [CI], 0.63 to 0.89; p = 0.001) [Fig 1].

Acute coronary syndrome (ACS), which is associated with high rates of morbidity and mortality, refers to the spectrum of acute myocardial ischemia, including unstable angina (UA), ST-segment elevation myocardial ischemia, and acute myocardial ischemia without ST-segment elevation. The risk of recurrent ischemic events is greatest in the weeks and months immediately following ACS. Despite the widespread use of conventional therapies aimed at modifying platelet function and the coagulation cascade to reduce the risk of further ischemia, patients who have experienced an ACS continue to be at high cardiac risk. Nearly 25% of men and 38% of women die within 1 year of having a first myocardial infarction (MI). These statistics highlight the need for improved strategies that target the pathophysiologic mechanisms operating in ACS and treat the underlying atherosclerotic disease.

Evidence from numerous large, randomized, controlled trials- unequivocally demonstrates the ability of statins to reduce coronary morbidity and mortality. However, while the benefits of statin therapy in patients with stable coronary artery disease (CAD) are clearly recognized, it is only recently that the positive impact of initiating statin treatment immediately following the occurrence of ACS has emerged.” This review will present evidence supporting early initiation of statin therapy in ACS, including results from hospital-based initiatives that guide physicians to prescribe statins prior to patient discharge in order to improve treatment rates, patient adherence, and clinical outcomes reached with concern of My Canadian Pharmacy.